The prevalence of adolescent depression and other internalizing mental health problems has increased in recent years, whereas the prevalence of externalizing behaviors has decreased. The association ...of these changes with the use of mental health services has not been previously examined.
To examine national trends in the care of different mental health problems and in different treatment settings among adolescents.
Data for this survey study were drawn from the National Survey on Drug Use and Health, an annual cross-sectional survey of the US general population. This study focused on adolescent participants aged 12 to 17 years interviewed from January 1, 2005, to December 31, 2018. Data were reported as weighted percentages and adjusted odds ratios (aORs) and analyzed from July 20 to December 1, 2019.
Time trends in 12-month prevalence of any mental health treatment or counseling in a wide range of settings were examined overall and for different sociodemographic groups, types of mental health problems (internalizing, externalizing, relationship, and school related), and treatment settings (inpatient mental health, outpatient mental health, general medical, and school counseling). Trends in the number of visits and nights in inpatient settings were also examined.
A total of 47 090 of the 230 070 adolescents across survey years (19.7%) received mental health care. Of these, 57.5% were female; 31.3%, aged 12 to 13 years; 35.8%, aged 14 to 15 years; and 32.9%, aged 16 to 17 years. The overall prevalence of mental health care did not change appreciably over time. However, mental health care increased among girls (from 22.8% in 2005-2006 to 25.4% in 2017-2018; aOR, 1.11; 95% CI, 1.04-1.19; P = .001), non-Hispanic white adolescents (from 20.4% in 2005-2006 to 22.7% in 2017-2018; aOR, 1.08; 95% CI, 1.03-1.14; P = .004), and those with private insurance (from 19.4% in 2005-2006 to 21.2% in 2017-2018; aOR, 1.11; 95% CI, 1.04-1.18; P = .002). Internalizing problems, including suicidal ideation and depressive symptoms, accounted for an increasing proportion of care (from 48.3% in 2005-2006 to 57.8% in 2017-2018; aOR, 1.52; 95% CI, 1.39-1.66; P < .001), whereas externalizing problems (from 31.9% in 2005-2006 to 23.7% in 2017-2018; aOR, 0.67; 95% CI, 0.62-0.73; P < .001) and relationship problems (from 30.4% in 2005-2006 to 26.9% in 2017-2018; aOR, 0.75; 95% CI, 0.69-0.82; P < .001) accounted for decreasing proportions. During this period, use of outpatient mental health services increased from 58.1% in 2005-2006 to 67.3% in 2017-2018 (aOR, 1.47; 95% CI, 1.35-1.59; P < .001), although use of school counseling decreased from 49.1% in 2005-2006 to 45.4% in 2017-2018 (aOR, 0.86; 95% CI, 0.79-0.93; P < .001). Outpatient mental health visits (eg, private mental health clinicians, from 7.2 in 2005-2006 to 9.0 in 2017-2018; incidence rate ratio, 1.30; 95% CI, 1.23-1.37; P < .001) and overnight stays in inpatient mental health settings (from 4.0 nights in 2005-2006 to 5.4 nights in 2017-2018; incidence rate ratio, 1.18; 95% CI, 1.02-1.37; P = .03) increased.
This study's findings suggest that the growing number of adolescents who receive care for internalizing mental health problems and the increasing share who receive care in specialty outpatient settings are placing new demands on specialty adolescent mental health treatment resources.
Summary Background Evidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed. We assessed the effect of performance-based ...payment of health-care providers (payment for performance; P4P) on use and quality of child and maternal care services in health-care facilities in Rwanda. Methods 166 facilities were randomly assigned at the district level either to begin P4P funding between June, 2006, and October, 2006 (intervention group; n=80), or to continue with the traditional input-based funding until 23 months after study baseline (control group; n=86). Randomisation was done by coin toss. We surveyed facilities and 2158 households at baseline and after 23 months. The main outcome measures were prenatal care visits and institutional deliveries, quality of prenatal care, and child preventive care visits and immunisation. We isolated the incentive effect from the resource effect by increasing comparison facilities' input-based budgets by the average P4P payments made to the treatment facilities. We estimated a multivariate regression specification of the difference-in-difference model in which an individual's outcome is regressed against a dummy variable, indicating whether the facility received P4P that year, a facility-fixed effect, a year indicator, and a series of individual and household characteristics. Findings Our model estimated that facilities in the intervention group had a 23% increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger (56%) and aged between 24 months and 59 months (132%). No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules. We also estimate an increase of 0·157 standard deviations (95% CI 0·026–0·289) in prenatal quality as measured by compliance with Rwandan prenatal care clinical practice guidelines. Interpretation The P4P scheme in Rwanda had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider. P4P financial performance incentives can improve both the use and quality of maternal and child health services, and could be a useful intervention to accelerate progress towards Millennium Development Goals for maternal and child health. Funding World Bank's Bank-Netherlands Partnership Program and Spanish Impact Evaluation Fund, the British Economic and Social Research Council, Government of Rwanda, and Global Development Network.
Through detailed discussion of inpatient geriatric psychiatry, telehealth models of care, health staff concerns, and social determinants of health, as well as nonclinical factors that affect the ...broader clinical effort, Geriatric Mental Health Care provides techniques that health care providers can use to overcome the challenges of the current pandemic-and prepare for the next one.
Conditional cash transfers (CCT) provide monetary transfers to households on the condition that they comply with some pre-defined requirements. CCT programmes have been justified on the grounds that ...demand-side subsidies are necessary to address inequities in access to health and social services for poor people. In the past decade they have become increasingly popular, particularly in middle income countries in Latin America.
To assess the effectiveness of CCT in improving access to care and health outcomes, in particular for poorer populations in low and middle income countries.
We searched a wide range of international databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, in addition to development studies and economic databases. We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature. The original searches were conducted between November 2005 and April 2006. An updated search in MEDLINE was carried out in May 2009.
CCT were defined as monetary transfers made to households on the condition that they comply with some pre-determined requirements in relation to health care. Studies had to include an objective measure of at least one of the following outcomes: health care utilisation, health expenditure, health outcomes or equity outcomes. Eligible study designs were: randomised controlled trial, interrupted time series analysis, or controlled before-after study of the impact of health financing policies following criteria used by the Cochrane Effective Practice and Organisation of Care Group.
We performed qualitative analysis of the evidence.
We included ten papers reporting results from six intervention studies. Overall, design quality and analysis limited the risks of bias. Several CCT programmes provided strong evidence of a positive impact on the use of health services, nutritional status and health outcomes, respectively assessed by anthropometric measurements and self-reported episodes of illness. It is hard to attribute these positive effects to the cash incentives specifically because other components may also contribute. Several studies provide evidence of positive impacts on the uptake of preventive services by children and pregnant women. We found no evidence about effects on health care expenditure.
Conditional cash transfer programmes have been the subject of some well-designed evaluations, which strongly suggest that they could be an effective approach to improving access to preventive services. Their replicability under different conditions - particularly in more deprived settings - is still unclear because they depend on effective primary health care and mechanisms to disburse payments. Further rigorous evaluative research is needed, particularly where CCTs are being introduced in low income countries, for example in Sub-Saharan Africa or South Asia.
Objective: Although schools are identified as critical for detecting youth mental disorders, little is known about whether the number of mental health providers and types of resources that they offer ...influence student mental health service use. Such information could inform the development and allocation of appropriate school-based resources to increase service use. This article examines associations of school resources with past-year mental health service use among students with 12-month "DSM-IV" mental disorders. Method: Data come from the U.S. National Comorbidity Survey Adolescent Supplement (NCS-A), a national survey of adolescent mental health that included 4,445 adolescent-parent pairs in 227 schools in which principals and mental health coordinators completed surveys about school resources and policies for addressing student emotional problems. Adolescents and parents completed the Composite International Diagnostic Interview and reported mental health service use across multiple sectors. Multilevel multivariate regression was used to examine associations of school mental health resources and individual-level service use. Results: Nearly half (45.3%) of adolescents with a 12-month "DSM-IV" disorder received past-year mental health services. Substantial variation existed in school resources. Increased school engagement in early identification was significantly associated with mental health service use for adolescents with mild/moderate mental and behavior disorders. The ratio of students to mental health providers was not associated with overall service use, but was associated with sector of service use. Conclusions: School mental health resources, particularly those related to early identification, may facilitate mental health service use and may influence sector of service use for youths with "DSM" disorders. (Contains 3 tables.)
Background: Little is known about the treated prevalence and services received by children and adolescents in low‐ and middle‐income countries (LAMICs). The purpose of this study is to describe the ...characteristics and capacity of mental health services for children and adolescents in 42 LAMICs.
Methods: The World Health Organization Assessment Instrument for Mental Health Systems (WHO‐AIMS), a 155‐indicator instrument developed to assess key components of mental health service systems, was used to describe mental health services in 13 low, 24 lower‐middle, and 5 upper‐middle‐income countries. Child and adolescent service indicators used in the analysis were drawn from Domains 2 (mental health services), 4 (human resources), and 5 (links with other sectors) of the WHO‐AIMS instrument.
Results: The median one‐year treated prevalence for children and adolescents is 159 per 100,000 population compared to a treated prevalence of 664 per 100,000 for the adult population. Children and adolescents make up 12% of the patient population in mental health outpatient facilities and less than 6% in all other types of mental health facilities. Less than 1% of beds in inpatient facilities are reserved for children and adolescents. Training provided for mental health professionals on child and adolescent mental health is minimal, with less than 1% receiving refresher training. Most countries (76%) organize educational campaigns on child and adolescent mental health.
Conclusions: Mental health services for children and adolescents in low‐ and middle‐income countries are extremely scarce and greatly limit access to appropriate care. Scaling up of services resources will be necessary in order to meet the objectives of the WHO Mental Health Gap Action (mhGAP) program which identifies increased services for the treatment of child mental disorders as a priority.
More than 20 countries in Africa are scaling up performance-based financing (PBF), but its impact on equity in access to health services remains to be documented. This paper draws on evidence from ...Rwanda to examine the capacity of PBF to ensure equal access to key health interventions especially in rural areas where most of the poor live. Specifically, it focuses on maternal and child health services, distinguishing two wealth groups, and uses data from a rigorous impact evaluation. Difference-in-difference technique is used, and different model specifications are tested: control for unobserved heterogeneity and common random error using linear probability model, seemingly unrelated regression equations, and clustering and fixed effects. Results suggest that in Rwanda, PBF improved efficiency rather than equity for most health services. We find that PBF achieved efficiency gains by improving access to health services for those easier to reach, generally the relatively more affluent. It turns out to be less effective in reaching the poorest. Our results illustrate the advantages of rigorous randomized impact evaluation data as results published earlier using a nationally representative survey (Demographic and Health Survey) were not able to capture the pro-rich nature of the PBF scheme in Rwanda. Our paper advocates for building mechanisms targeting the vulnerable groups in PBF strategies. It also highlights the need to understand the impact of PBF together with the specific development of health insurance coverage and the organization of the health system.
In Bahia, Brazil, the decades following emancipation saw the rise of reformers who sought to reshape the citizenry by educating Bahian women in methods for raising "better babies." The idealized ...Brazilian would be better equipped to contribute to the labor and organizational needs of a modern nation. Backed by many physicians, politicians, and intellectuals, the resulting welfare programs for mothers and children mirrored complex debates about Brazilian nationality. Examining the local and national contours of this movement, Progressive Mothers, Better Babies investigates families, medical institutions, state-building, and social stratification to trace the resulting policies, which gathered momentum in the aftermath of abolition (1888) and the declaration of the First Republic (1889), culminating during the administration of President Getúlio Vargas (1930–1945). Exploring the cultural discourses on race, gender, and poverty that permeated medical knowledge and the public health system for almost a century, Okezi T. Otovo draws on extensive archival research to reconstruct the implications for Bahia, where family patronage politics governed poor women's labor as the mothers who were the focus of medical interventions were often the nannies and nursemaids of society's wealthier families. The book reveals key transition points as the state of Bahia transformed from being a place where poor families could expect few social services to becoming the home of numerous programs targeting the poorest mothers and their children. Negotiating crucial questions of identity, this history sheds new light on larger debates about Brazil's past and future.
Despite the evidence showing that young people aged 12-25 years have the highest incidence and prevalence of mental illness across the lifespan, and bear a disproportionate share of the burden of ...disease associated with mental disorder, their access to mental health services is the poorest of all age groups. A major factor contributing to this poor access is the current design of our mental healthcare system, which is manifestly inadequate for the unique developmental and cultural needs of our young people. If we are to reduce the impact of mental disorder on this most vulnerable population group, transformational change and service redesign is necessary. Here, we present three recent and rapidly evolving service structures from Australia, Ireland and the UK that have each worked within their respective healthcare contexts to reorient existing services to provide youth-specific, evidence-based mental healthcare that is both accessible and acceptable to young people.
The value of integrated team delivery models is not firmly established.
To evaluate the association of receiving primary care in integrated team-based care (TBC) practices vs traditional practice ...management (TPM) practices (usual care) with patient outcomes, health care utilization, and costs.
A retrospective, longitudinal, cohort study to assess the association of integrating physical and mental health over time in TBC practices with patient outcomes and costs.
Adult patients (aged ≥18 years) who received primary care at 113 unique Intermountain Healthcare Medical Group primary care practices from 2003 through 2005 and had yearly encounters with Intermountain Healthcare through 2013, including some patients who received care in both TBC and TPM practices.
Receipt of primary care in TBC practices compared with TPM practices for patients treated in internal medicine, family practice, and geriatrics practices.
Outcomes included 7 quality measures, 6 health care utilization measures, payments to the delivery system, and program investment costs.
During the study period (January 2010-December 2013), 113,452 unique patients (mean age, 56.1 years; women, 58.9%) accounted for 163,226 person-years of exposure in 27 TBC practices and 171,915 person-years in 75 TPM practices. Patients treated in TBC practices compared with those treated in TPM practices had higher rates of active depression screening (46.1% for TBC vs 24.1% for TPM; odds ratio OR, 1.91 95% CI, 1.75 to 2.08), adherence to a diabetes care bundle (24.6% for TBC vs 19.5% for TPM; OR, 1.26 95% CI, 1.11 to 1.42), and documentation of self-care plans (48.4% for TBC vs 8.7% for TPM; OR, 5.59 95% CI, 4.27 to 7.33), lower proportion of patients with controlled hypertension (<140/90 mm Hg) (85.0% for TBC vs 97.7% for TPM; OR, 0.87 95% CI, 0.80 to 0.95), and no significant differences in documentation of advanced directives (9.6% for TBC vs 9.9% for TPM; OR, 0.97 95% CI, 0.91 to 1.03). Per 100 person-years, rates of health care utilization were lower for TBC patients compared with TPM patients for emergency department visits (18.1 for TBC vs 23.5 for TPM; incidence rate ratio IRR, 0.77 95% CI, 0.74 to 0.80), hospital admissions (9.5 for TBC vs 10.6 for TPM; IRR, 0.89 95% CI, 0.85 to 0.94), ambulatory care sensitive visits and admissions (3.3 for TBC vs 4.3 for TPM; IRR, 0.77 95% CI, 0.70 to 0.85), and primary care physician encounters (232.8 for TBC vs 250.4 for TPM; IRR, 0.93 95% CI, 0.92 to 0.94), with no significant difference in visits to urgent care facilities (55.7 for TBC vs 56.2 for TPM; IRR, 0.99 95% CI, 0.97 to 1.02) and visits to specialty care physicians (213.5 for TBC vs 217.9 for TPM; IRR, 0.98 95% CI, 0.97 to 0.99, P > .008). Payments to the delivery system were lower in the TBC group vs the TPM group ($3400.62 for TBC vs $3515.71 for TPM; β, -$115.09 95% CI, -$199.64 to -$30.54) and were less than investment costs of the TBC program.
Among adults enrolled in an integrated health care system, receipt of primary care at TBC practices compared with TPM practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system.
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